Missouri Title V Facts: Oral Health Care Background Establishing and maintaining good oral health is integral to establishing and maintaining good overall physical health. Oral health care should start early in a child’s life –the American Academy of Pediatrics recommends that all children receive at least one dental examination yearly, beginning approximately 6 months after appearance of the first tooth. Parents of children with good oral health report that their children have higher self-esteem and better school performance, and parents report that they themselves have lower stress levels. Poor oral health can lead to the development of caries (cavities, tooth decay), which continue to represent one of the most common chronic health conditions faced by children in the United States. Caries in children are associated not only with infection, but also with speech and eating problems, poor school performance, and behavioral disturbances.1 An estimated 81,500 Missouri children (6%) have poor oral health,2with children and youth with special health care needs (CYSHCN) twice as likely as non-SHCN youth to have fair-to-poor oral health. Despite being one of the most common childhood conditions, caries are also one of the most preventable. An estimated 25 to 40 percent of cavities in young individuals can be prevented through the application of fluoride varnish twice yearly.3 Children aged 5-8 with full lifetime exposure to fluoridated municipal water were half as likely as children without exposure to fluoridated water to develop tooth decay.4 Regular dental examinations offer an opportunity to identify and correct tooth decay and poor oral health in a timely manner, reducing the lifetime likelihood of major dental problems. Access to Oral Health Services Figure 1. Fluoridated Municipal Water Systems in Missouri Nearly 170 communities in Missouri actively fluoridate their Fluoride in Missouri municipal water supplies; an Public Water Supplies additional 296 municipalities Public Water Systems that Serve Water with Fluoride Concentrations have naturally-occurring fluoride equal to or greater than 0.6 mg/L concentrations above the 0.6 20 40 80 Miles parts per million recommended for chemical fluoridation, covering approximately 76% of Natural Fluoride the state’s population.5 However, Added Fluoride rural residents who may not have access to a municipal water supply are less likely to experience the benefits of water fluoridation. Residents of rural counties are also less likely to have received a past-year preventive dental visit Only primary public water systems shown All public water systems shown here than non-rural residents (31% have naturally-occurring levels of Fluoride in source water greater than or equal to 0.6 mg/Lor chemically add Fluoride to water to achieve this concentratiOn rural vs. 44% non-rural).6 Data shown based on monitoring records from 2014, 2015, and 2016 612017 1 Missouri Title V Facts: Oral Health Care Many Missourians have limited access to dental and oral health services due to socioeconomic factors. MO HealthNet, “If you have Medicaid, some [dentists] the Missouri Medicaid program, does not will only take so many appointments cover dental services for adults who are not pregnant or blind, though it does each day with that type of insurance. cover dental care for children under 18. I need it now, I can’t wait.” Annually, there are approximately 60,000 emergency department (ED) visits due to non-traumatic dental complaints among Missouri residents annually; based on national estimates, these visits cost approximately $17.5 million per year. However, even when services are fully covered, some citizens experience challenges scheduling appointments or finding an available dentist who accepts MO HealthNet. Figure 2. Percent of Medicaid Eligibles6 to 14 Data from MO HealthNet indicates that Years Old -Received at Least One Dental Missouri is significantly below the national Sealant in 2015 and 2016 average in the percent of Medicaid-eligible children ages 6 to 14 receiving at least one 15% 15% dental sealant for the years 2015 through 2017. 13% 12% Among all third graders in 2016-2017, 30% had dental sealants. Parents and caregivers of CYSHCN may also have difficulty locating National ■ dentists or hygienists able to accommodate the Missouri additional medical or behavioral needs of their ■ children, potentially contributing to elevated rates of dental decay in this population.7 2015 2016 Health Professional Shortage Area (HPSA) Figure 3. Dental HPSAs in Missouri n Not Designated is a designation that indicates that an Low Income area does not have enough health care ■ Geographic resources to meet the need of its ■ High Need Geographic residents. HPSAs can occur when there 1 St Francois 2 Sainte Genevieve are too few, if any, providers in an area; 3 Cape Girardeau 4 St Louis when there are more patients than providers can see; or when transportation barriers prevent patients from reaching providers.8 95 areas in Missouri were designated as dental HPSAs in 2018, 79 of which were in rural counties. Large sections of Missouri are designated as HPSAs due to low incomes, in conjunction with other factors such as long travel times or low provider numbers. 2 Missouri Title V Facts: Oral Health Care Trends in Oral Health Tooth decay does not affect all populations equally. Only 2.4% of Missouri children younger than 6 have fair or poor tooth condition, compared to 8% of children aged 6 to 17. Black, or African American, youths have higher rates of poor oral health than white youths (13% vs 5%), though the difference is not statistically significant. Oral health in children and adolescents improves with increasing household income and parental education. A survey of Missouri third-graders indicated that over half (55%) had some degree of tooth decay, with rates significantly higher among children in rural counties (64%) than urban (50%). Children attending schools with <75% participation in the national free/reduced price school lunch program (NSLP) (as a proxy for poverty) had nearly twice the odds of having tooth decay than children at schools with >25% NSLP participation. Overall, 28% of Missouri’s third-grade children need dental care, including 5% needing urgent dental care due to pain or infection.9 The mouth is not immune from the physiologic changes that occur during pregnancy, and pregnant women may begin to experience gingivitis, tooth loosening, or tooth erosion or caries associated with pregnancy-induced nausea and vomiting.10 However, 57% of Missouri mothers who gave birth in 2018 did not have a preventive dental visit during pregnancy, and 27% did not see a dentist in the year before they became pregnant. Though 26% of pregnant women reported that they needed to see a dentist for a dental or oral health concern, only 16% of those women ultimately received care for that problem. One in ten mothers additionally report that they are unsure whether it is safe to receive dental treatment while pregnant.11 What is Being Done? Missouri Oral Health Integration and Improvement Initiative (MOHIII): This initiative expands on activities outlined in the State Oral Health Plan, including: extending the reach of dental sealant programs; increasing the number of communities with fluoridated water; and enhancing medical- dental integration. Teledentistryand Access to Care:Missouri is among 18 states that allow Medicaid to directly reimburse dental hygienists, with the goal of improving access to dental care for low income Missourians.12The Missouri Coalition for Oral Health has implemented trainings for providers on providing oral health services through telemedicine/teledentistry. Preventive Services Program (PSP): the PSP is an evidence-based fluoride varnish and oral health education program. Each child receives an oral health screening by a dental professional, two doses of fluoride varnish, oral health literature and supplies, and oral health education. The oral health education is either provided by school staff or the dental professionals that volunteer to operate PSP. Educational materials are also provided. PSP served over 91,000 children during the 2018-2019 school year. Water Fluoridation:During FY19, ODH conducted a water fluoridation media campaign. Messages highlighted the importance of drinking fluoridated water and the importance of regular dental check-ups and good oral hygiene habits. The media campaign targeted southeast Missouri, however, the radio PSAs were broadcast statewide by the Missouri Broadcaster’s Association at no additional charge to the state. 3 Missouri Title V Facts: Oral Health Care References: 1. Sharna, N., Ramakrishnan, M., Samuel, V., Ravikumar, D., Cheenglembi, K., & Anil, S. (2019). Association between Early Childhood Caries and Quality of Life: Early Childhood Oral Health Impact Scale and PufaIndex. Dentistry Journal, 7(4), 95. 2. Child and Adolescent Health Measurement Initiative. 2017-2018 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). http://www.childhealthdata.org. Accesssed February 12, 2020. 3. Bonetti, D., & Clarkson, J. E. (2016). Fluoride varnish for caries prevention: efficacy and implementation. Caries research, 50(Suppl. 1), 45-49. 4. Spencer, A. J., Do, L. G., & Ha, D. H. (2018). Contemporary evidence on the effectiveness of water fluoridation in the prevention of childhood caries. Community dentistry and oral epidemiology, 46(4), 407-415. 5. Missouri Department of Health and Senior Services, Office of Dental Health. Water Fluoridation in Missouri Communities. https://health.mo.gov/living/families/oralhealth/pdf/fluoridationmap.pdf. Accessed January 28, 2020. 6. Missouri Department of Health and Senior Services, Office of Rural Health and Primary Care. Health in Rural Missouri Biennial Report, 2019. https://health.mo.gov/living/families/ruralhealth/pdf/biennial2019.pdf. Accessed December 16, 2019. 7. DHSS Bureau of Epidemiology and Vital Statistics, Title V Needs Assessment Focus Group Summary Report. 2020. 8. Health Resource and Service Administration. HPSA Find. https://data.hrsa.gov/tools/shortage-area/hpsa-find. Accessed February 12, 2020. 9. Missouri Department of Health and Senior Services, Office of Dental Health, Basic Screening Survey, 2016-2017. 10. American College of Obstetricians and Gynecologists. (2013). Oral health care during pregnancy and through the lifespan. ObstetGynecol, 122(2), 417-22. 11. Missouri Department of Health and Senior Services (DHSS), Bureau of Epidemiology and Vital Statistics. Pregnancy Risk Assessment Monitoring System, 2018. 12. American Dental Hygienists' Association. (2015). Facts about the dental hygiene workforce in the United States. Available at: https://www.adha.org/resources-docs/75118_Facts_About_the_Dental_Hygiene_Workforce.pdf. Accessed February 12, 2020. 4